PRIORITY HEALTH SERVICES
MATERNAL RISK SCREENING TOOL
MATERNAL INFANT HEALTH PROGRAM
PATIENT INFORMATION
Patient
Name
Date of Birth
Medicaid ID #
Due Date
Street Address
City, State, Zip
Parent/Guardian/Spouse
Phone Number
Additional Contact Person
Alternate Phone Number
HEALTH
CARE (OBSTETRICAL) PROVIDER
Health Care Provider Name
Health Provider Street Address
Health Provider City, State, Zip
Health Provider Phone Number
Health Plan :Office Only
Referral Source
NEED FOR CHILDBIRTH EDUCATION
Do you know what to expect during pregnancy?
N/A
YES
NO
Do you want to learn more about delivery?
N/A
YES
NO
Do you have experience in taking care of a baby?
N/A
YES
NO
Do you want to learn more about how to take care of your baby?
N/A
YES
NO
NEED FOR TRANSPORTATION TO KEEP MEDICAL APPOINTMENTS
Do you have a ride to get to medical appointments?
N/A
YES
NO
How do you get there?
Car
Bus/Taxi
Other
Have you ever missed a medical appointment because of a ride?
N/A
YES
NO
NEED FOR ASSISTANCE TO CARE FOR YOUR INFANT
Do you have trouble reading?
N/A
YES
NO
Do you have trouble understanding instructions from your Dr.?
N/A
YES
NO
Is English your first language?
N/A
YES
NO
Do you have trouble taking care of yourself physically?
N/A
YES
NO
What was the last grade you finished in school?
Where do you live?
Rent Apt/Home
Own Home
Relative
Shelter
Motel
Car
NUTRITION HEALTH/PROBLEMS
How many meals do you eat a day?
Do you skip meals?
N/A
YES
NO
Do you mostly:
Cook At Home
Eat Fast Food
Which do you drink more of?
Pop
Juice
Water
Milk
Do you have enough money to buy food?
N/A
YES
NO
Is your blood low in iron?
N/A
YES
NO
Do you have high blood pressure?
N/A
YES
NO
Do you have diabetes now or during other pregnancies?
N/A
YES
NO
Have you had problems with weight gain or loss during your pregnancy?
N/A
YES
NO
Do you have any other health problems that worry you?
FAMILY SUPPORT
Who can you count on for support:
(Use Shift Key to Select more than one answer )
SELECT
Babys Father Yes
Babys Father No
A Parent No
A Friend Yes
A Friend No
A Parent Yes
Who do you live with?
FEELINGS ABOUT CURRENT PREGNANCY
Have you been pregnant before?
N/A
YES
NO
How many times have you been pregnant?
What are your feelings about this pregnancy?
Happy
Unhappy
Do Not Know
Did your last pregnancy result in your baby being born early?
N/A
YES
NO
Have you had a death of one of your children before age one?
N/A
YES
NO
MOTHER WITH COGNITIVE, EMOTIONAL OR MENTAL NEEDS
How are you doing overall with taking care of yourself and your child/children?
Good
Bad
O.K.
Do you feel stressed?
N/A
YES
NO
Do you have a history of postpartum depression?
N/A
YES
NO
Are you worried about your mental and emotional health?
N/A
YES
NO
SOCIAL SITUATION
Do you worry about someone mistreating you?
N/A
YES
NO
Do you worry about someone mistreating your child/children?
N/A
YES
NO
Do you have trouble paying your bills?
N/A
YES
NO
USE OF ALCOHOL, DRUGS OR TOBACCO PRODUCTS
Do you smoke?
N/A
YES
NO
Do you drink alcohol (beer, wine, liquor) now that your are pregnant?
N/A
YES
NO
Do you use street drugs?
N/A
YES
NO
Does someone in your household use street drugs?
N/A
YES
NO
IS
THERE ANYTHING ELSE YOU WANT TO TELL US OR THAT WE CAN HELP YOU WITH:
FORM COMPLETED BY:
DATE:
EMAIL:
PHONE: